As medical educators, we are continually challenged to prepare the next generation of physicians. This means providing the skills and knowledge to those who will provide health care for years to come. Given the continually changing health-care landscape, combined with multiple external pressures, this task is becoming increasing complex. This article will review some of the challenges that currently exist in both the health-care landscape and medical education continuum. It will conclude with how these challenges should be addressed and questions that should be considered as we move forward.

The 21st century has brought a myriad of challenges/opportunities with it. The changing and diversifying world population, the expansion of both knowledge creation and knowledge promulgation – aided by the invention and spread of access to the Internet – are all items that have led to a challenging health-care environment. This has also resulted in a series of challenges for the current medical education system and those tasked with preparing the next generation of physicians.

It has been over 100 years since Abraham Flexner made a series of recommendations that have shaped medical education in North America and beyond. In that intervening time period, there have been a series of reports from a number of institutions calling for medical education reform worldwide.[1],[2],[3],[4],[5],[6],[7],[8],[9] The changes articulated in the reports range from the addition of skills deemed necessary for practice in today's changing health-care environment to further improve knowledge and for the preparation of medical students with regard to decisions concerning medical specialty's choice to complete curriculum reform to a competency-based rather than time-based system.[2],[4],[5],[7]

To date, none of these reports have been fully integrated into the continuum of education found at any medical school. In North America, the current state of undergraduate medical education (UME) generally follows the model laid out in the Flexner Report – that is, 2 years of preclinical study focusing on the basic sciences followed by 2 years of clinical study in a teaching hospital (usually academic) grounded in the university system. Flexner had emphasized the importance of the university structure to the development of a strong medical education system.[10] This importance remains true to this day as is illustrated by the following quote “undergraduate medical education being conferred through university frameworks is integral to the training of our future health care professionals.”[11] However, there exists a shift within the medical education continuum to transform from a time-based to a competency-based system.

Cyclical reimaginations of the medical education system have typically occurred on a regular basis, generally starting in resource-rich settings to respond to external and internal pressures with eventual spread to other settings. What is noticed is that, over a period of time, there tends to be a shifting of the pendulum back to the “norm” or status quo with slight modifications. The shifting landscape is also considerably influenced by the response of learners and their perceptions and expectations of the medical education system.

Changes to the basis of curricula provide both opportunities and threats. The opportunities that exist are reflected in the fact that a massive overhaul provides the opportunity to have additional information and experiences related to medical specialties and the decision-making process deliberately included within the medical school experience. When major changes are undertaken, often decision makers are overwhelmed by the changes they need to undertake and therefore are not willing to make additional changes to the existing curriculum. In order to be able to integrate additional topics into the curriculum, educators must have a more thorough understanding of the information that will facilitate the acquisition of skills that will be necessary for 21st century practice, a practice that is continually changing in response to the changing demands of the health-care system in which the physicians operate.

External Pressures on the System

Several key external pressures have impacted the medical education system over the decade and will likely continue to do so for the years to come. The changing public sphere impacts medical specialty's choice in two ways. First, increased public interest and advocacy has shifted the way medicine is being practiced. This increased scrutiny has been amplified by the prevalence of the availability of information and dissemination of knowledge. In the digital knowledge age that currently exists, information on the symptoms and processes of diseases is readily available to anyone with internet access. Also readily available, in many jurisdictions, are physicians' ratings and any complaints that may have been made against them. The combination of these two factors has resulted in a public that has access to a greater amount of information than previous ones. This results in a shift in the way physicians interact with the public at large, patients, and other stakeholders in the multiple decision-making processes. For the patient care process, the additional information means that the public at large have a greater amount of information available to them and are not fully reliant on the physicians to be the sole source of information necessary for decision-making and management planning. For the medical specialty's decision-making process, the breadth of information and ease of access mean that medical students have a wealth of information at their disposal. However, the access to this information does not include the ability to triage the information for accuracy and relevance or the wisdom to consider appropriate application to specific clinical cases. Often, the access to this amount of information complicates, rather than simplifies, the decision-making process.

The shift in age, distribution, and composition of the population results in a change in demands for medical services. In North America and many other settings, as the average age of the population increases, there will be larger demand for medical services and medical specialties that are related to the care of older adults and less of a demand for those related to the younger population.[12] For example, the demand for vascular surgeons, urologists, and geriatricians will likely increase in these jurisdictions, whereas the demand for pediatricians will decrease. Whereas in other settings, where the demographics are more heavily based in a younger population, the needs will be different. In addition, as people are living longer, it is shifting the medical care they require as they live with conditions that once were acute but are now chronic. For example, patients who have undergone certain surgical procedures with grafts or devices implanted that have an expected “life span” of 15–20 years are in some cases outliving these implants. This example illustrates some of the developments that need to be addressed in a shifting and aging population. This is a shift from the previous health-care landscapes and is not currently addressed by the current training paradigms.[12]

Current State of Medical Education

What is also evident is that there are demands on the medical education system itself. There are limited resources at each level of training and often these levels occur in a siloed format, despite efforts to reduce this effect. While the “levels” are often defined by the shift from one level of responsibility to another, that is UME to postgraduate/residency medical education (PGME) to continuing professional development (CPD); within each of these areas, there is also fragmentation that detracts from a holistic development of a physician. Given the manner in which medical training is inculcated, the fact that individual and siloed practices continue at the level of the practicing physician should not come as a surprise. Additionally, while a shift to continuing professional development from continuing medical education for practicing physicians has been encouraged, there remains limited evidence of this shift in more than name only.

For many who have completed traditional medical education before beginning clinical practice, their experience can be summarized as one of the fragmentations, that is, fragmented clinical exposures, fragmented learning experiences, and fragmented assessment opportunities. The traditional Flexnerian structure of a biomedical “preclerkship” followed by a clinical “clerkship” period in UME unfortunately leads to the siloed or compartmentalized training found in most PGME programs and also CPD opportunities. This fragmented structure has evolved over the decades to include a typical dependence on didactic teaching methods, apprenticeship models with a greater focus on summative assessments, and a limited to no focus on formative feedback, thereby supporting the learners' progression and professional development. Attitudinally, many trainees have been engrained with a sense of desiring formal teaching to drive their learning when perhaps instead they should be approaching their experiences with a lifelong learning mentality, where any activities or responsibility can have a learning component that is important to their development of competencies on route to transitioning to practice. Furthermore, this model of medical education has been heavily reliant on residents and faculty for teaching when they have had limited or no faculty or teacher to provide key foundational elements for effective and efficient teaching to their learners. These factors as a result contribute to the creation of an environment where growing clinical pressures will compete with and often overcome formal teaching for limited time and resources.

While technology has played, as noted previously, a significant role in accessing information, both for patients and providers, it is also increasingly playing a role in health care itself. This is evident through the development and implementation of electronic health records, the use of remote health, and even the growing exploration of machine learning and artificial intelligence to support care delivery. What is being noted, however, is the lack of preparedness of the existing medical education system to be involved with the shaping and development of these technologies, let alone determining their appropriate implementation and usage so as to improve patient care, patient experience, and provider experience rather than negatively impact them. Over the next few years physicians will increasingly need to engage with technology and also those responsible for their development. As a result this will require additional competencies and concepts for our current physicians that our current medical education system cannot provide, and also the identification of additional learning gaps as we prepare individuals for a future that may not resemble the present reality in which they are training.

The continually changing medical education landscape, and the health-care systems it supports, results in a series of opportunities for those tasked with preparing the next generation of physicians. In order to meet these challenges, medical educators must be willing to explore the multifaceted nature of the health-care system and welcome a multitude of educational experiences to create a robust medical education continuum. These are the challenges that educators face regardless of the level of training or geographical location – these challenges compel educators to continue to broaden their perspectives and revisit their biases. Without doing this, we will not be able to attain the goal of training physicians who are equipped to face the tasks of 21st-century practice.